What services are covered by TennCare?

Below are some of the services covered by TennCare. For a complete list of TennCare benefits and limits, visit the benefits page of the TennCare website

  • Specialists: A specialist is a doctor who gives care for a certain illness or part of the body. One kind of specialist is a cardiologist, who is a heart doctor. Another kind of specialist is called an oncologist, who treats cancer. There are many kinds of specialists. Your PCP may send you to a specialist for care. This is called a referral. If your PCP wants you to go to a specialist, he or she will set up the appointment with the specialist for you.
  • Wellness and Preventive Care: TennCare covers most medical services necessary for physical and mental health, including hospital, physician, and pharmacy services. If you are having problems getting the medical care you need and want help working with your health plan call us at 1-800-758-1638.
  • Dental: TennCare only covers dental care for children under the age of 21. TennCare’s dental health plan is called TennDent. Their phone number is 1-877-418-6886. If you have questions about caring for your child’s teeth, call them. It’s a free call. For a copy of the TennDent member handbook, click here.

TennCare does not cover any dental care, including oral surgery, for adults age 21 and older. For more information go to your TennCare member handbook.

  • Mental Health: Mental health services include physician and facility or residential treatment, mental health case management, and substance abuse treatment services. For more information, call your health plan. If you still need help, call us at 1-800-758-1638, Monday – Friday 8am – 6pm Central Standard Time.
  • Transportation: If you don’t have a way to get to your health care visits, you may be able to get a ride from TennCare. If you need a ride to your health care visits, call your health plan. Try to call at least one week before your health care visit to make sure that you can get a ride. If you change times or cancel your health care visit, you must change or cancel your ride too.

You can get help with a ride:

• only for services covered by TennCare, and

• only if you don’t have any other way to get there.

If you are a child under the age of 21, you can have someone ride with you.

For the most up-to-date information about transportation, call your health plan. The number for your health plan is on the back of your TennCare card.
See a list of health plan contact numbers.

  • Children’s Health Care: Services are available to children with TennCare through the TENNderCare Program, in accordance with the federal Early Periodic Screening, Diagnostic, and Treatment (EPSDT) program. It is a full program of check ups and health care services for babies, children, teens, and young adults who have TennCare. See more information on the care your child will receive through EPSDT at the TENNderCare Program website.
  • TennCare Pharmacy Benefit Most pharmacies have contracts with TennCare. You may also look in your member handbook to see which pharmacies you can go to, or you can call your pharmacy health plan at 1-888-816-1680.
  • Prescription Drugs: Most, but not all, TennCare members have a prescription benefit. To find out if you have TennCare prescription benefits, go to your TennCare member handbook or call us at 1-800-758-1638.

For members with TennCare Prescription Benefits:

Preferred Drug List: TennCare has a list of medications called a Preferred Drug List or PDL. This is sometimes called a formulary. TennCare’s PDL lists the medications that TennCare pays for, as well as the rules and limitations necessary to meet medical necessity criteria. This list can change. Click here to see the current Preferred Drug List.

Prior Authorization: Some medications need a prior authorization (PA), or TennCare’s OK, even if they are listed on the PDL. Most doctors know about the PA process and will work with SXC (TennCare’s pharmacy health plan) to request an OK. But, sometimes your prescription may be denied because your doctor didn’t request an OK, or the PA has not been processed yet, or SXC denied the PA. If your prescription has been denied, call the TennCare Advocacy Program for help at 1-800-758-1638, Monday – Friday 8am – 6pm Central Standard Time.

Pharmacy Benefit Limits: Children with TennCare pharmacy benefits have no pharmacy limit. But, for most adults with TennCare pharmacy benefits, TennCare only pays for 5 prescriptions or refills each month. Only 2 of the 5 prescriptions can be brand name drugs. At least 3 must be generic. A generic works the same as a brand name drug, but usually costs less. What if you need more than limits allow? TennCare has an Over the Limit list and an Exempt list that may help you.

Over the Limit List of Drugs: The Over the Limit List (also called the Provider Attestation List) is a list of drugs you can get after you’ve reached your prescription limit if your doctor gets TennCare’s OK. To find out more about this list, go to TennCare’s website and click on Prescriber Attestation List (Over the Limit).

The Exempt List of Drugs: The Exempt List (also called the Automatic Exemption List) is a list of drugs that will not count against the prescription limit. To find out more about this list, go to TennCare’s website and click on Automatic Exemption List (Exempt).